Clinical Pathway for Laryngectomy Patients (place on Clipboard)

Time

Teaching points

Clinical progression/ Interdisciplinary responsibilities

Pre-Op

Discuss pain expectations

Treatment Options
Document key elements for handof
Show Educational DVD: pre-op consent,
what to expect in hospital, emergency
planning send home with video

Patient able to make informed decision about best treatment

option
Patient is healthy/stable enough to go through with surgery
MD
H&P
Order SLP consult
Present at tumor board
SP
Pre & post op A&P and functional deficits
Permanency of tracheostoma and importance of
stoma cares
Patient has support system available to help through
this journey
Functional communication options
Pain expectations
Home medical supplies

Post Op
day 0

Revised: 4/9/15

Inform about pain control options:

Medication options, timing, routes of
administration

Incision cares:
Per MD orders, usually clean and apply
ointment to avoid crusting

Stoma cares:
Reinforce importance of patent stoma
Suctioning, saline bullets (as needed
for thick mucous), spraying with
water/saline
Often increased suctioning needs
immediately post-operatively
Make sure to explain what you are

RN

Read Pre Op note by Speech Pathologist in Chart Review

Tab in EPIC: should include important information with
implications for care
Maximize anti-nausea medications
Follow-up on routine post-operative labs and CXR
Ensure appropriate position of feeding tube (if applicable)
Post-op check (hematoma, stoma patency, JP drain
function, etc)
Make patient Acuity 3 until patient is independent delegate other tasks to make sure education is completed

MD

Send surgical kit for Laryngectomy with patient (Post Op

Clinical Pathway for Laryngectomy Patients (place on Clipboard)

Time

Teaching points

doing and why to the patient

remember, this is the first time they
will be experiencing this type of airway
irritation!

Clinical progression/ Interdisciplinary responsibilities

Initiation of routine post-operative

cares:
DVT prophylaxis, NGT cares, etc.
Provide appropriate supplies for the
patient at their bedside:
Larygectomy supply kit (tablet, pen,
picture boards, spray bottle, saline,
pen light, forceps, med alert bracelet)
from medication room in drawer
place patient sticker on tracking sheet

supplies)
Enter comprehensive, clear post-op orders (Post Op
Laryngectomy Order Set to be created) including post op
nausea and pain management
Order appropriate consults: nutrition, speech pathology,
physical therapy
F/u on routine post op labs and CXR
Ensure position of feeding tube as necessary
Post op check and note

Explain importance of humidified

trach mask

Explain importance of keeping stoma

clean

Post Op
day 1

Use mirror and ask them to assess

their incisions and stoma
Begin the process of making the
patient comfortable with their new
anatomy

Involve the patient in stoma and

incision cares through observation
Have them use handheld mirror to look
on while you perform various stoma
cares
Explain the use and importance of
suctioning, saline bullets, spraying with
water/saline

Revised: 4/9/15

RN
JP drain output and function - assure patency and
appropriate functioning
Ensure patient is utilizing tracheal mask for humidified air
Ensure stoma is clean and patent
Assess neck for fullness, edema, erythema (signs of
hematoma and/or fistula)
Ensure adequate pain control
Incentive Spirometry or Cough and deep breath 10x/hr
while awake
MD
Assess for active bowel sounds and consider starting tube
feeds slowly

Clinical Pathway for Laryngectomy Patients (place on Clipboard)

Time

Teaching points

Review patients pain control options

with them
Explain the purpose of NG tube and
begin feeds if ordered by MDs

Teach signs and symptoms of infection

(erythema, warmth, edema, fever,
chills, increased pain) and importance
of notifying clinic

Start showing Patient education

Videos on education channel

Family or support system has been

present or available

Patient/family has established

emergency communication plan (TTY,
text messaging, other)

Post Op
day 2

Continue to graduate responsibility of independent

stoma cares to the patient and family.
Evaluate whether patient understands when
to provide cares (suctioning, dressing
changes, cleaning stoma this should still
be happening about every shift yet)

Revised: 4/9/15

Clinical progression/ Interdisciplinary responsibilities

Reassess patients suctioning needs and modify orders as

appropriate
As tube feeds are being stared, keep total fluids at 100-125
ml/hr
Once switched to bolus, make sure adequate free water
boluses have been ordered and are being tolerated prior to
discontinuing IV fluids

SLP
Introduce HME (Heat Moisture Exchange) device
Establish functional means of communication
Reinforce importance of patent stoma
Engage caregiver in education process
Explain and demonstrate stoma cares
Send test script through to insurance to verify which DME
company is covered by insurance
MD
Ambulate at least TID or per PT recommendations
Assess patients tolerance of tube feedings and adjust
accordingly
Assess: neck, stoma, drains, bowel sounds, suctioning
needs, pain control
Foley removal order or document acceptable indication
RN
Encourage patient to participate in own wound and stoma
cares
Encourage patient and family to ask questions if they have
them
Progressive activity:
o Patient should be ambulating by POD #2, advanced

Clinical Pathway for Laryngectomy Patients (place on Clipboard)

Time

Teaching points

Post Op
day 3 -5

Clinical progression/ Interdisciplinary responsibilities

as they become free of tubes/lines

SLP
Assess functionality of communication method
Initiate electrolarynx training per pt readiness/request
Graduate responsibilities for independent stoma care
MD
Continued assessment and modification (if needed) of:
stoma, wounds, drains, feeding tolerance, suctioning
needs, pain control
Begin daily order clean-up to avoid redundant and or
outdated orders. Discontinue irrelevant orders to avoid
confusion
Ensure clear activity orders are written for each day as
activity is advanced
Discuss with patient, nursing staff, social worker,
case manager and discharge flow coordinator
anticipated day of discharge and document this in the
daily progress note. Ask about other needs identified. Case
manager orders supplies and sets up home care. Social
worker establishes placement (rehab, LTAC)
Ensure that any home health needs are set up and
confirmed if the anticipated day of discharge is on the
weekend

Ensure that patient is able to teach back

importance of cares, when to contact the
MD or when to contact emergency response
system and how.
Reinforce that with time, the frequency of
these cares will become less. As frequency
of suctioning decreases will transition to
HME
Evaluate if the patient understands when to
change HME, remove (for coughing to
avoid plugging)

RN

Revised: 4/9/15

Continue cares as previously listed for POD #2

Document any delay in progression in care and
communicate with treatment team.
Continue to encourage patient participation in own wound
and stoma cares
Ensure understanding by patient of his anatomy and cares
that need to be done

Clinical Pathway for Laryngectomy Patients (place on Clipboard)

Time

Teaching points

Clinical progression/ Interdisciplinary responsibilities

Communicate with care team regarding patients

progress towards independence on the following items for
discharge planning: stoma cares, wound cares,
understanding of own anatomy, coping strategies, support
system. Work with physicians, case manager, social
worker, and discharge planner regarding anticipated
discharge needs
SLP
Continue to advance cares and independence of
patient/family with self-management skills
MD (ideally done the day before discharge)

Discharge
Day

Progress towards readiness for

discharge

Assessment and achievement of goals

For patient and family/support
system

Educate patient and family about

importance of stoma cares, including
limiting crusting and the importance of
humidification and suctioning/coughing
up of secretions

Educate patient and family about stoma

protection during ADLs

Swallowing

2-4 weeks
post-op
Revised: 4/9/15

TEP Neophonation

Ensure that prescriptions have been printed and on the

chart

Update AVS instructions

RN

Make sure that the patient/Family has had all questions

answered and ensure teach back of d/c instructions
SLP
Complete Atos Medical Prescription for laryngectomy
supplies (LaryTubes, HMEs, brushes, shower shield, flush,
holders, etc)
Complete Home Care request form for laryngectomy
supplies and give to case manager
Provide Stoma cover (and red rubber catheters if TEP
patient)
Perform radiographic leak study before/after discharge per
physicians request. Once cleared for PO, start patient on
full liquid diet and/or pureed textures. Slowly advance to
more difficult textures as tolerated.
SLP
With medical clearance, place prosthesis and/or begin TEP

Clinical Pathway for Laryngectomy Patients (place on Clipboard)

Time

Teaching points

Lymphedema

Revised: 4/9/15

Clinical progression/ Interdisciplinary responsibilities

voice training
Monitor for lymphedema and refer to physician as needed.